Cognition, imagery and coping among adolescents with social anxiety and phobia: testing the Clark and Wells model in the population.

UNLABELLED: The Clark and Wells' cognitive model of social phobia suggests that self-focused attention, negative observer-perspective images of oneself and safety behaviours maintain anxiety in subjects with SP. Empirical research among adults supports the model, but limited evidence for it has been obtained in other age groups or in the general population. We examined automatic thoughts, imagery, safety behaviours and general coping of adolescents with social anxiety and phobia. These were elicited by a thought listing procedure in a recalled, distressing social situation. The target variables were compared between adolescents with high versus normal self-reported social anxiety (HSA/NSA) and between adolescents with clinical/subclinical SP (SP/SSP) versus no diagnosis. Adolescents with HSA reported overall negative thoughts, negative observer-perspective images and safety behaviours more frequently than adolescents with NSA. The SP/SSP group displayed the same difference, and clearer, relative to the no diagnosis group, but additionally reported negative thoughts focused more often on self. Minor differences in coping were found between the groups. The study suggests that adolescents with SP already display the negative self-focused cognitions, observer-perspective imagery and behavioural pattern found among adults with SP. KEY PRACTITIONER MESSAGE: Social anxiety associates with observer-perspective imagery and safety behaviours in adolescence. Adolescents with clinical social phobia report frequent negative self-focused thoughts. However, such negative cognitions focused on self do not associate to self-reported social anxiety. The cognitive model of social phobia (Clark & Wells, 1995) is applicable to adolescents.

The Mini-Social Phobia Inventory: psychometric properties in an adolescent general population sample.

BACKGROUND: Onset of social phobia (SP) typically occurs in adolescence. Short screening instruments for its assessment are needed for use in primary health and school settings. The 3-item Mini-Social Phobia Inventory (SPIN) has demonstrated effectiveness in screening for generalized SP (GSP) in adults. This study examined the psychometrics of the Mini-SPIN in an adolescent general population sample. METHODS: Three hundred fifty adolescents aged 12 to 17 years were clinically interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version for identification of SP and other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders, blind to their Mini-SPIN status. Associations between SP; subclinical SP; other anxiety, depressive, and disruptive disorders; and Mini-SPIN scores were examined, and diagnostic efficiency statistics were calculated. The association between Mini-SPIN scores and the generalized subtype of SP was also examined. RESULTS: As in adults, the Mini-SPIN items differentiated subjects with SP from those without. A score of 6 points or greater was found optimal in predicting SP with a sensitivity of 86%, specificity of 84%, and positive and negative predictive values of 26% and 99%. The Mini-SPIN also possessed discriminative validity, as scores were higher for adolescents with SP than they were for those with depressive, disruptive, and other anxiety disorders. The Mini-SPIN was also able to differentiate adolescents with GSP from the rest of the sample. CONCLUSIONS: The Mini-SPIN has good psychometrics for screening SP in adolescents from general population and may have value in screening for GSP.

Social phobia in Finnish general adolescent population: prevalence, comorbidity, individual and family correlates, and service use.

BACKGROUND: Few studies have investigated the epidemiology of social phobia (SP) among early to middle adolescents, at the time of suggested mean onset of the disorder. The objective of this study was to investigate the prevalence, comorbidity, individual and familial correlates, and service use associated with SP among Finnish 12-17-year-old adolescents in general population. METHODS: A sample of 784 adolescents was screened with the Social Phobia Inventory, and a sub-sample (n=350) was interviewed with a semi-structured clinical interview to identify SP, sub-clinical SP (SSP), and a range of other axis I DSM-IV disorders. Individual and familial correlates, and service use associated with SP were also inquired. RESULTS: We found a 12-month prevalence of 3.2% for SP, and 4.6% for SSP. The prevalence rose and the gender ratio shifted to female preponderance as age increased. SP was frequently comorbid with other anxiety disorders (41%) and depressive disorders (41%). Adolescents with SP/SSP were impaired in their academic and global functioning, and reported more parental psychiatric treatment contacts. Two thirds (68%) of adolescents with SP reported having been bullied by peers. Only one fifth of adolescents with non-comorbid SP had been in contact with a mental health professional. CONCLUSIONS: We conclude that adolescent SP is a relatively frequent, undertreated and highly comorbid condition, associated with educational impairment, depression and anxiety in parents, and peer victimization.

Screening social phobia in adolescents from general population: the validity of the Social Phobia Inventory (SPIN) against a clinical interview.

Social phobia (SP) has onset during early adolescence, and is associated with significant impairment in social and educational functioning of adolescents. Therefore, valid and easy-to-use tools for screening and identification of SP among adolescent community populations are needed. We investigated both construct and discriminative validity, and screening properties of the 17-item Social Phobia Inventory (SPIN) relative to SP diagnoses based on a semi-structured clinical interview (K-SADS-PL), in a sample of 752 12 to 17-year-old Finnish students from general population. The SPIN demonstrated good properties to differentiate adolescents with SP and those with sub-clinical SP symptoms (SSP), from adolescents without SP. The SPIN also differentiated adolescents with SP from those with depressive and disruptive disorders. In this sample 27% of participants scored above the previously suggested SPIN cut-off (15 points) for adolescent SP. We suggest using a somewhat higher cut-off score, 24 points, when using the SPIN as a screen for SP in general adolescent populations. This cut-off score resulted in a sensitivity of 81.2%, a specificity of 85.1%, a positive predictive value of 26.9%, and a negative predictive value of 98.6% in relation to the SP diagnosis in our sample. To screen for both SP and SSP, 19 points as a cut-off score produced satisfactory diagnostic efficiency statistics. The SPIN appears to have good properties for screening and identification of adolescent SP.

Transparent criteria for specialist level adolescent psychiatric care.

BACKGROUND: Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0-100, with 50 as an entry threshold. OBJECTIVE: To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. METHOD: Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. RESULTS: Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. CONCLUSION: The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.

Psychosocial functioning needs attention in adolescent eating disorders.

We studied the differences in psychosocial functioning in the early stages of adolescent anorexia nervosa (AN) and bulimia nervosa (BN). The study group comprised 57 adolescent eating disorder (ED) outpatients (girls). Psychosocial functioning was evaluated by GAF (Global Assessment of Functioning), and by Morgan-Russell psychosocial subscales. GAF scores were very low in both AN and BN. On the Morgan-Russell subscales, bulimics reported more unsatisfactory relationships with family and impairment in work/school. Anorectics tended to have more difficulties in emancipation from family and in social contacts. Multivariate analysis showed associations of BN and high GSI with difficulties in relationships with family and of AN with difficulties in emancipation from family and with fewer social activities. Longer duration of illness predicted best impaired working ability. In adolescent EDs, psychosocial functioning is markedly impaired. We emphasize the importance of evaluating psychosocial functioning at the very onset of ED.

Psychopathological distress predicts suicidal ideation and self-harm in adolescent eating disorder outpatients.

OBJECTIVE: This study evaluated the differences in suicidal behaviour between adolescent anorexia nervosa (AN) and bulimia nervosa (BN), and the association of age, menarche timing, duration of eating disorder (ED), depression and general psychopathological symptoms (GSI) with suicidal behaviour in adolescent ED. METHODS: The study group comprised 57 adolescent outpatients (girls) attending for assessment because of eating disorders. Suicidal ideation, deliberate self-harm and suicidal attempts were assessed in self-report questionnaires. RESULTS: In both ED groups, one adolescent had attempted suicide before assessment. Suicidal ideation and/or deliberate self-harm were reported in over half of the cases. Bulimics had significantly more suicidal ideation and deliberate self-harm than anorectics. In multivariate analysis, BN and depression predicted suicidal ideation, but only GSI persisted as predicting deliberate self-harm. CONCLUSIONS: Suicidal behaviour is common in adolescent ED. Type of ED (BN), depression and higher GSI are strongly associated with suicidal ideation and deliberate self-harm. Our results point to the need to evaluate psychopathological symptoms in adolescent ED, especially in BN, in the initial assessment to prevent severe suicidal behaviour.

Biological and photochemical degradation rates of diethylenetriaminepentaacetic acid (DTPA) in the presence and absence of Fe(III).

The environmental fate of ethylenediaminetetraacetic acid (EDTA) has been extensively studied, while much less is known about the environmental behaviour of diethylenetriaminepentaacetic acid (DTPA). In this study, it was confirmed that DTPA is persistent toward biodegradation. The biodegradability of DTPA was investigated in the absence and in the presence of Fe(III) by using CO2 evolution test and Manometric respirometry test. The CO2 evolution and oxygen uptake of iron-free (DTPA was added as free acid) and Fe(III)DTPA were less than in inoculum blank. Possible inhibitor effect was analysed by testing biodegradation of sodium benzoate with and without iron-free or Fe(III)DTPA in the Manometric respirometry test. Only slight inhibition was observed when DTPA was added as free acid. Photodegradation of iron-free DTPA and Fe(III)-DTPA complex was studied by using sunlight and UV radiation at the range 315-400 nm emitted by black light lamps. The results indicate that DTPA added as free acid degrades photochemically in humic lake water. Fe(III)DTPA was shown to be very photolabile in humic lake water in the summer; the photochemical half-life was below one hour. Photodegradation products were identified by the mass spectrometric technique (GC-MS). It was shown that photodegradation of Fe(III)DTPA does not result in total mineralization of the compound. Diethylenetriaminetetraacetic acid, diethylenetriaminetriacetic acid, ethylenediaminetriacetic acid, N,N'- and/or N,N-ethylenediaminediacetic acid, iminodiacetate, ethylenediaminemonoacetic acid and glycine were identified as photodegradation products of Fe(III)DTPA. Based on these observations, we propose a photodegradation pathway for Fe(III)DTPA.

Puberty, sexual development and eating disorders in adolescent outpatients.

This study examined puberty and psychosexual state in a clinical sample of adolescents attending for assessment because of eating disorders (ED). A total of 57 adolescents (girls) aged 14-21 years (mean age 16.9 years) having either anorexia nervosa (AN) or bulimia nervosa (BN) were studied by semi-structured interviews and structured self-report questionnaires considering the timing of menarche, dating and attitudes to sexuality. The age at menarche did not differ statistically significantly between AN and BN. It was significantly lower in the BN group than in the normal population, but no statistically significant difference was found between the AN group and normal population. The general attitudes to sexuality were more negative in the AN group than in the BN group. In the AN group, there were also fewer dating experiences and interest in dating than in the BN group. After controlling for the effect of age, age at menarche and duration of ED, negative attitudes to sexuality and no dating experiences were still best predicted by AN. The results suggest different ways of coping with the developmental challenges in sexuality in AN and BN during adolescence.

Early puberty is associated with mental health problems in middle adolescence.

This study set out to assess the relationship between pubertal timing and emotional and behavioural problems in middle adolescence. The study involved a school based survey of health, health behaviour and behaviour in school as well as questions about emotional and behavioural problems (the School Health Promotion Study). Secondary schools in four regions and 13 towns in Finland participated in the study in 1998. The respondents were 36,549 adolescents aged 14-16. The study included questions on depression, bulimia nervosa, psychosomatic symptoms, anxiety, drinking, substance use, smoking, bullying and truancy. Among girls, both internalising and externalising symptoms were more common the earlier puberty occurred. Among boys, externalising symptoms only were associated with early puberty. It is concluded that early pubertal timing is associated with increased mental health problems. Professionals working with adolescents should consider the mental health needs of early maturing adolescents.

Bulimia and impulsive behaviour in middle adolescence.

BACKGROUND: In clinical samples, bulimia seems to be associated with various dyscontrol behaviours suggesting weakness in impulse control. Population studies of adolescents, however, are needed. We evaluated the association between self-reported bulimic behaviour and a number of dyscontrol behaviours, namely bullying, truancy, excessive drinking and sexual disinhibition among adolescents aged 14-16. This is the first study on bulimia and impulsivity in a large non-selected adolescent population sample. METHODS: A self-report questionnaire was administered to a representative population sample of 14- to 16-year-old adolescents (pupils of the 8th and the 9th grades of secondary school in four different regions in Finland). 4,453 girls and 4,334 boys aged 14-16 participated. The participation rate was 85.5%. RESULTS: Bulimic behaviour was associated with bullying, truancy, excessive drinking and sexual disinhibition among both sexes. Odds ratios for bulimic-type eating pathology according to each of these behaviours varied between 1.7 and 4.1. The more dyscontrol behaviours occurred simultaneously, the more likely was bulimic-type eating pathology. CONCLUSIONS: There is an association between bulimic behaviour and dyscontrol behaviours in the general population of adolescent girls and boys.

Are adolescents with frequent pain symptoms more depressed?

OBJECTIVE: To study predicting value of pain symptoms in detecting depression among adolescents. DESIGN: A population-based classroom survey of 14-16-year-old adolescents. SETTING: Secondary schools in two regions of Finland (Vaasa and Pirkanmaa). SUBJECTS: Every secondary school in these two regions was asked to participate in the study. The final sample comprised 17,643 adolescents in 8th and 9th grades (mean age 15.3 years). MAIN OUTCOME MEASURES: The subjects were asked to rate the frequency of headache, stomach-ache, low back pain and neck or shoulder pain. Depression was measured using the Finnish modification of the short Beck Depression Inventory (R-BDI). Trait anxiety was questioned in an item formulated analogously to R-BDI questions. RESULTS: Prevalence of depression was higher among adolescents with recurrent pain symptoms. Each of the four measured pain symptoms predicted depression independently and accumulation of different pain symptoms increased the odd ratios for depression. Anxiety did not change the association between pain symptoms and depression. CONCLUSION: Recurrent pain symptoms are associated with depression among adolescents. Clinicians working with adolescents should be aware of this association and interview adolescents with recurrent pains for possible underlying depression.